Define Phase Tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION chapter chapter 02 © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDefine PhaseNOT FOR Tools SALE OR DISTRIBUTION

“A goal without a plan is just a wish.”

© Jones & Bartlett Learning, LLC —Antoine de Saint-Exupery© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION “In preparing for battle I have always found that plans are useless, but planning is indispensable.”

—General Dwight D. Eisenhower © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE“An ORexpert DISTRIBUTION is one who avoids the small errors whileNOT sweeping FOR on SALEto the OR DISTRIBUTION grand fallacy.”

—Anonymous © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Background Every improvement project must start with a thorough understanding of ©the Jones quality &issue Bartlett to be improved. Learning, A common LLC error at this stage is to© assume Jones & Bartlett Learning, LLC NOTthat one FOR person’s SALE perception OR DISTRIBUTION of a problem is correct, without examiningNOT FOR SALE OR DISTRIBUTION supporting data or at least other perceptions that can provide more insight into an issue. The Define Phase of the improvement cycle avoids such errors through a structured problem analysis that examines an issue and © Jones & Bartlettdevelops Learning, a process map LLC to unambiguously communicate© Jones the & elementsBartlett of Learning, LLC a process that are working well and those that are not working very well. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION One key to an effective improvement effort is a clear understanding of the 21

22 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC process,NOT FORas well SALE as the ORgoals DISTRIBUTION and objectives for change. The deliverablesNOT FOR SALE OR DISTRIBUTION from the Define Phase help communicate process issues and improvement goals in a manner that should be understandable by all stakeholders. Define Phase tools that will be discussed in this chapter include the following: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Project OR DISTRIBUTION charter NOT FOR SALE OR DISTRIBUTION • Voice of the Customer • Kano model • Stakeholder analysis © Jones & Bartlett Learning,• Process LLC mapping, including SIPOC© Jones process & Bartlett map Learning, LLC NOT FOR SALE OR DISTRIBUTION• Brainstorming and its variantsNOT FOR SALE OR DISTRIBUTION • Multivoting and list reduction • Affinity diagram • Critical-to-quality (CTQ) analysis © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTThe goal FOR of SALEapplying OR these DISTRIBUTION tools is to produce several key deliverables,NOT FOR SALE OR DISTRIBUTION including:

• Fully trained team © Jones & Bartlett• Customers Learning, identified LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• High OR impactDISTRIBUTION characteristics (CTQs) defined NOT FOR SALE OR DISTRIBUTION • Team charter • Process mapped • Adequate budget © Jones & Bartlett Learning,• Senior LLC leadership support © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The key to ensuring a highly effective outcome for the project is inherent in those deliverables.

Project© Jones & Bartlettcharter Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION It is useful to think of the charter as a contract between leaders and the project team. Created at the outset of the project, the purposes of the project charter are numerous: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • To clearly state the purpose and goals of the project NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • To provide background on the reason(s) for the project

projeCt Charter 23

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• To FOR ensure SALE alignment OR DISTRIBUTION of project and team goals with organizationalNOT FOR SALE OR DISTRIBUTION priorities • To identify resources available and constraints for the project • To delineate deliverables and define success © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC The project charter is the document that the team leader uses continu- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ously to keep the team focused on the task and expected outcomes. Other stakeholders usually receive an executive summary of the project to serve as a reminder of the project’s importance, timeline, and deliverables. Senior managers can refer to the project charter when evaluating resource alloca- © Jones & Bartlett Learning,tion LLCdecisions to ensure that the© return Jones from & the Bartlett project Learning,is justified by LLC the NOT FOR SALE OR DISTRIBUTIONexpected outcome. NOT FOR SALE OR DISTRIBUTION Project charters vary substantially in structure and content, but in general the document should include the elements listed in Table 2-1 and include the following: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• Background FOR SALE and OR purpose DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • What prompted the interest in the project? • Where is the project positioned in the organization’s priorities? • Which organizational leaders and/or departments are most inter- © Jones & Bartlett estedLearning, and invested LLC in the outcome? © Jones & Bartlett Learning, LLC NOT FOR SALE OR• Which DISTRIBUTION systems in the organization have beenNOT malfunctioning FOR SALE ORand DISTRIBUTION to what extent? • What is the underlying reason for the project (e.g., cost contain- ment, patient safety, member satisfaction, etc.)? © Jones & Bartlett Learning, LLC• Over what period of time© has Jones the issue & Bartlettdeveloped? Learning, LLC NOT FOR SALE OR DISTRIBUTION• How quickly does the organizationNOT FOR need SALE a solution? OR DISTRIBUTION

Table 2-1 Project charter contents

©Charter Jones element & Bartlett Description Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Background and • Description of the process or issue to be addressed and its purpose importance to the business • Problems with the current process—what motivated the project? © Jones & BartlettMission Learning,statement • SuccinctLLC statement of the project ©purpose Jones and &goals Bartlett that Learning, LLC NOT FOR SALE OR DISTRIBUTIONincludes the purpose and directionNOT for the FOR team SALE OR DISTRIBUTION • Links to organizational mission statement should be evident

24 Chapter 2 Define phase tools

Charter element Description

Scope • Boundaries and limitations © Jones & Bartlett Learning,• Project LLC outcomes—what goals must the© projectJones achieve? & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Project milestones—timeline of steps (sometimesNOT FOR called SALE OR DISTRIBUTION “gates”) that will be achieved during the project • Deliverables—what reports, measures, processes, products, or services will the project deliver when complete? • Cost estimates—budgetary limits for the project, including staff © Jones & Bartlett Learning, LLC time and costs for© other Jones resources & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION • Organizational interfaces—departmentsNOT FOR SALE or ORworkgroups DISTRIBUTION expected to be affected by the project • Other stakeholders affected by the project • Urgency/priority of the project • Source of team empowerment (e.g., Senior Vice President © Jones & Bartlettof Health Learning, Services) and LLCallowed functions (e.g., review and© Jones & Bartlett Learning, LLC execute contracts) NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Team composition • List of functional areas, skills, levels of expertise, and external and roles stakeholders who need to be represented on the team, usually divided into core team members and extended team members • In some cases, specific names may be included in the list • Roles for each of the team members (e.g., leader, subject © Jones & Bartlett Learning,matter LLC expert, recorder, etc.) © Jones & Bartlett Learning, LLC NOT FOR SALEOperational OR DISTRIBUTION• Special environmental factors (e.g., teamNOT work FOR locations, SALE soft- OR DISTRIBUTION framework ware, computers, etc.) • Accountability—who on the team is accountable for which parts of the project? • Decision-making processes—methods for making and reporting © Jones & Bartlett Learning, LLC decisions (e.g., majority© Jones vote, super & Bartlett majority, weighted Learning, voting) LLC NOT FOR SALE OR DISTRIBUTION • Conflict resolutionNOT rules andFOR procedures—final SALE OR authority DISTRIBUTION for any conflicts that arise • Process improvement tools and procedures • Procedures for changing team members and/or leaders Performance • Measures of team performance, such as deadlines for deliverables measures© Jones & Bartlett• In-process Learning, metrics to determine LLC level of success for team,© such Jones & Bartlett Learning, LLC NOT FOR SALEas results OR ofDISTRIBUTION pilot test, process efficiency measures NOT FOR SALE OR DISTRIBUTION • Outcome measures for project (e.g., goals achieved) Support Any other support needed, like consultants, special measurement requirements systems, facilities, outside vendors © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

projeCt Charter 25

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• Mission FOR SALE statement OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Succinctly describe the mission of this project; mission statements should be two or three sentences at most and capture the essence of the goals and objectives of the effort • Relationship of the project mission to the organizational mission © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC statement NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Scope • Departments and divisions affected by the project • Economic and budgetary limits for project activities and recom- mendations © Jones & Bartlett Learning, LLC• Business and work processes© Jones affected & by Bartlett the proposed Learning, project LLC NOT FOR SALE OR DISTRIBUTION• Team composition and frameworkNOT FOR SALE OR DISTRIBUTION • Core team members—those team members who will participate throughout the project • Additional team members—those team members whose expertise © Jonesmay & be Bartlett needed from Learning, time to time,LLC but not continuously through© Jones- & Bartlett Learning, LLC NOT FORout the SALE project OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Consultants—specialized staff or external resource people who may be needed for specific issues • Support staff—administrative staff who facilitate the team’s work, © Jones & Bartlett suchLearning, as taking LLC and preparing meeting notes,© Jones arranging & forBartlett meeting Learning, LLC NOT FOR SALE ORspace, DISTRIBUTION etc. NOT FOR SALE OR DISTRIBUTION • Operational framework—the improvement or planning paradigm to be used by the team for executing the project; for example, the team may use a company-specific improvement model or the DMAIC © Jones & Bartlett Learning, LLCmodel or perhaps a lean model© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Performance measures—a NOTlist of FOR all measures SALE thatOR DISTRIBUTIONwill be used to assess the project, including: • Structural—infrastructure elements required for a project or the underlying process to be improved; these measures can involve © Jonesequipment, & Bartlett staffing, Learning, capital investment, LLC physical facilities, ©or Jonesinfor- & Bartlett Learning, LLC NOT FORmation SALE systems OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Process—in-process metrics usually include milestones or “gates” that indicate the project is proceeding according to the planned schedule © Jones & Bartlett• Learning,Outcome—these LLC measures vary widely© by Jones project, & butBartlett usually Learning, LLC NOT FOR SALE ORinclude DISTRIBUTION an implementation plan for the NOTnew process, FOR SALE as well ORas a DISTRIBUTION “scorecard” of measures to assess the process going forward

26 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• Support FOR requirements—any SALE OR DISTRIBUTION other support requirements not NOTprevi- FOR SALE OR DISTRIBUTION ously mentioned in the charter, such as particular senior leader team sponsorship In some cases, the executive(s) that commission the project may provide © Jones & Bartlettthe charter, Learning, but if not, LLC then the leadership team for© Jones the project & Bartlett should Learning, LLC NOT FOR SALEensure ORthat DISTRIBUTIONa charter is created and confirmed by theNOT executive(s) FOR SALE before OR DISTRIBUTION starting to work. A project charter template is included as Figure 2-1 and at the online resource center for this book.

© Jones & Bartlett Learning,Voice LLC of the customer© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The best place to start with any project is a thorough understanding of the customer in as many dimensions as possible. Customer characteristics, like basic demographics (name, address, contact information) constitute some of ©the Jones key data & elements Bartlett of Learning, any project, LLCbut other traits, such as ethnicity,© Jones & Bartlett Learning, LLC gender,NOT andFOR age, SALE may alsoOR help DISTRIBUTION in project planning as a means of NOTtailor- FOR SALE OR DISTRIBUTION ing a service or product to a particular population. For example, if a team wanted to develop a program to improve blood pressure control in a population that included a subset of Mandarin Chinese people, then surveys and © Jones & Bartletteducational Learning, information LLC may need to be adapted to© accommodate Jones & Bartlett unique Learning, LLC NOT FOR SALElanguage OR and DISTRIBUTION cultural needs. This information is usedNOT to FOR develop SALE meth OR- DISTRIBUTION ods of obtaining the “Voice of the Customer” (VOC), which involves the process of capturing feedback from customers to better understand their requirements. The VOC process is not a one-time project, but rather systematic development of a “listening and learning” culture that obliges © Jones & Bartlett Learning,all employees LLC to collect formal and© informal Jones customer& Bartlett feedback Learning, to drive LLC NOT FOR SALE OR DISTRIBUTIONcontinuous improvement of the organization’sNOT FOR servicesSALE andOR products. DISTRIBUTION The VOC process needs to capture both stated and unstated customer requirements using tools such as those in Table 2-2. Perhaps the most widely used method of gaining insight into customer requirements in ©health Jones care & is Bartlett the standardized Learning, survey. LLC Companies like Press Ganey© Jones & Bartlett Learning, LLC (http://www.pressganey.com)NOT FOR SALE OR DISTRIBUTION and NRC Picker (http://www.nrcpicker.NOT FOR SALE OR DISTRIBUTION com) have developed validated questionnaires for healthcare organizations to use to query customers regarding issues like promptness of service, facility cleanliness, staff friendliness, time spent with the doctor, and other © Jones & Bartlettsatisfaction Learning, issues. These LLC services have substantial associated© Jones costs, & Bartlett and so Learning, LLC NOT FOR SALEmany smallerOR DISTRIBUTION providers (e.g., medical office practices)NOT are FORunable SALE to afford OR DISTRIBUTION to survey patients in this manner.

VoiCe of the Customer 27

Project Name: Project Number: Prepared by: (Project Manager)Date Submitted:

Customer: Department:Contact:Project Type: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Project Start Date: Project End Date: Milestone 1 Milestone 2Milestone 3Milestone 4Milestone 5Milestone 6 NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Background and Mission:

Business Goals:

Project Objectives: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOTDeliverables: FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Beneficiaries:

Key Requirements: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Resources:

Weekly Time Core Team:Name Department Start Date End Date Comment Commitment

©Adjunct Jones Team Members: & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

28 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Other Human Resoureces: NOTIT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Support Staff Consultant Ancillary Description Number or Degree Weekly Time Start Date End Date Comment Resources: Commitment

Travel © Jones & BartlettSupplies Learning, LLC © Jones & Bartlett Learning, LLC Software NOT FOR SALEHardware OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Training Other

Risk Assessment (With and Without Project): Risk if Project Done-risks Associated With Project © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Risks if Project not Done-business and Other Risks of Status Quo NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Constraints and Boundaries

Budget

NOT FOR SALE OR DISTRIBUTION $ NOT FOR SALE OR DISTRIBUTION -

$ -

$ © Jones & Bartlett Learning, LLC © Jones &- Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR $SALE OR DISTRIBUTION -

$ -

$ © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning,- LLC $ NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION-

$ -

$ $ $ $ $ $ $ $ $ Total © Jones &- Bartlett- - Learning,- - LLC- - - - © Jones & Bartlett Learning, LLC NOTSummary FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Sign Off:

© Jones & BartlettProject Learning, ManagerS LLC upervisor © ExecutiveJones Sponsor & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 2-1 Project charter template (continued)

VoiCe of the Customer 29

Formal Informal

Stated Individual structured interviews Individual open interviews © Jones & Bartlett Learning,Standardized LLC surveys “Quicky”© Jonesquestionnaires & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONFocus groups SpontaneousNOT groupFOR sessions SALE OR DISTRIBUTION Formal proposal specifications Customer inquiries and requests Complaint logs Customer complaints to staff Unstated Structured observation of customer Staff observations of customer © Jones & Bartlett Learning, LLC behavior © Jones behavior& Bartlett Learning, LLC Warranty data and product returns NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Medical-legal actions

Fortunately, the Agency for Healthcare Research and Quality (AHRQ, ©http://www.ahrq.gov) Jones & Bartlett has Learning, funded development LLC and validation of© a Jonesnum- & Bartlett Learning, LLC NOTber of FORsurvey SALE tools known OR DISTRIBUTION as the Consumer Assessment of HealthcareNOT Pro FOR- SALE OR DISTRIBUTION viders and Systems (CAHPS) surveys. Since these surveys were developed through federal grants, the surveys and comparison datasets are available on the AHRQ Web site at no charge. The CAHPS Consortium, a panel © Jones & Bartlettof survey Learning, experts, has LLC led the development of several© Jones instruments & Bartlett since Learning, LLC NOT FOR SALEthe ORmid-1990s DISTRIBUTION and continues to build and supportNOT a FOR wide-ranging SALE ORand DISTRIBUTION growing family of standardized surveys that poll consumers and patients on their experiences with health care and include such issues as provider communication skills and access to care. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONDetail: the cahpS cNOTonsortium FOR SALE OR DISTRIBUTION The CAHPS Consortium consists of federal agencies and private research organizations. The federal agencies include one of the primary funders of the project beginning with the first CAHPS survey for health plans, the Centers for Medicare & Medicaid Services (CMS). Other federal agencies involved in CAHPS include the ©Centers Jones for &Disease Bartlett Control Learning, and Prevention LLC and the National Institute for Disabil-© Jones & Bartlett Learning, LLC NOTity and FOR Rehabilitation SALE Research.OR DISTRIBUTION Private researchers are awarded grants for theirNOT FOR SALE OR DISTRIBUTION participation in the program and include experts in survey development, quality assessment and improvement, and reporting, such as Harvard Medical School, Research Triangle Institute, and RAND. For the second phase (CAHPS II), AHRQ funded five-year cooperative agreements with the American Institutes for Research, Harvard Medical School, and RAND, and for the most recent phase (CAHPS III), © Jones & Bartlettthe Consortium Learning, added LLC the Yale School of Public Health© and Jones RAND. The& Bartlett Agency Learning, LLC NOT FOR SALEalso OR has DISTRIBUTIONengaged Westat to support the work of the ConsortiumNOT FOR and the SALE CAHPS OR DISTRIBUTION User Network, as well as managing the National CAHPS Benchmarking Database.

30 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTCAHPS FOR surveys SALE include OR DISTRIBUTIONinstruments for assessing the quality ofNOT care FOR SALE OR DISTRIBUTION in both ambulatory and institutional settings, and each survey package includes the survey questionnaire, administration protocols, analysis and reporting guidelines programs, and guidance in reporting results.

© Jones & BartlettCAHPS SurveysLearning, and LLC the Voice of the Customer© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The first CAHPS survey was developed to measure consumer satisfaction with health plans, and this instrument has become the standard by which health plans are measured and, in recent years, classified for incentive programs. The CAHPS Health Plan Survey is used by com- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mercial, Medicaid, State Children’s Health Insurance Program (SCHIP), NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION and Medicare plans representing more than 120 million enrollees. Con- sumers can view results of the surveys on the CMS Web site (https:// www.cahps.ahrq.gov/CAHPSIDB/Public/About.aspx), and the CAHPS survey is one of the components behind the Medicare Star Ratings report © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC (http://www.cms.gov/PrescriptionDrugCovGenIn/06_PerformanceData .asp)NOT that FOR ranks SALEhealth plans OR DISTRIBUTIONon Health Effectiveness Data InformationNOT Set FOR SALE OR DISTRIBUTION (HEDIS), CAHPS, and Health Outcomes Survey (HOS) performance. Additionally, the National Committee for Quality Assurance (NCQA) incorporates CAHPS results into both its health plan performance reports © Jones & Bartlettas well as itsLearning, health plan LLC accreditation process. © Jones & Bartlett Learning, LLC NOT FOR SALEThe OR Consortium DISTRIBUTION also developed surveys duringNOT the secondFOR SALEphase ofOR DISTRIBUTION CAHPS that assess consumer experience in ambulatory settings, such as physician offices, managed behavioral healthcare organizations, dental plans, and tribal clinics. The standardized, validated approach to data acquisition © Jones & Bartlett Learning,and reporting LLC make them invaluable© Jonesfor any organization& Bartlett toLearning, measure the LLC NOT FOR SALE OR DISTRIBUTIONvoice of the customer in these specificNOT settings. FOR SALEAdditionally, OR DISTRIBUTION the ambulatory care survey1 includes optional supplemental items that may be added to specific instruments without changing the validity of the instrument. CAHPS surveys include instruments tailored for patient satisfaction measurement© Jones &in Bartlett other healthcare Learning, facilities, LLC such as hospitals, nursing© Jones & Bartlett Learning, LLC homes,NOT and FOR dialysis SALE centers. OR DISTRIBUTIONThe CAHPS Hospital Survey, often referredNOT FOR SALE OR DISTRIBUTION to as H-CAHPS or Hospital CAHPS, focuses on adult inpatient satisfaction with hospital care and services. Hospitals across the country have adopted the survey for measuring inpatient satisfaction and voluntarily © Jones & Bartlettreport their Learning, data to CMS LLC for inclusion in the CAHPS© Jones database & Bartlettused for Learning, LLC NOT FOR SALEbenchmarking OR DISTRIBUTION and comparisons. Another CAHPS NOTsurvey FORhas been SALE fielded OR DISTRIBUTION

VoiCe of the Customer 31

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTfor use FOR in hemodialysis SALE OR centers DISTRIBUTION for patients with end stage renalNOT disease, FOR SALE OR DISTRIBUTION and a nursing home survey is nearly ready for distribution.2 AHRQ supports the surveys through a variety of no-cost services, which include the CAHPS User Network and the National CAHPS Benchmark- ing Database. The CAHPS User Network helps users with technical ques- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC tions and allows users to interact with each other and CAHPS researchers. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The User Network provides the following resources:

• Free technical assistance—users can pose questions via a toll-free number (800-492-9261) and an e-mail address ([email protected]) © Jones & Bartlett Learning,• LLCA comprehensive CAHPS© Web Jones site &(www.cahps.ahrq.gov Bartlett Learning,), which LLC NOT FOR SALE OR DISTRIBUTIONhouses the following: NOT FOR SALE OR DISTRIBUTION • CAHPS Survey and Reporting Kits—questionnaires, reporting measures, administration protocols, analysis programs, and instruc- tions for using the CAHPS products © Jones• New & and Bartlett upcoming Learning, CAHPS LLCproducts © Jones & Bartlett Learning, LLC NOT• FORResources SALE to ORsupport DISTRIBUTION implementation of a survey project,NOT public FOR SALE OR DISTRIBUTION reporting of survey results, use of CAHPS surveys to improve quality, and translation of CAHPS surveys to other languages • Searchable FAQs and bibliography © Jones & Bartlett• MaterialsLearning, and LLC other information developed© Jones for CAHPS & Bartlett events, Learning, LLC NOT FOR SALE ORwebcasts, DISTRIBUTION and national user group meetingsNOT FOR SALE OR DISTRIBUTION • Resources designed to support users in identifying and networking with other organizations that are doing similar or related work • Newsletter—The CAHPS Connection newsletter3 keeps users © Jones & Bartlett Learning, LLCinformed about new programs,© Jones events, & and Bartlett survey changesLearning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION National CAHPS Benchmarking Database Not only does the CAHPS survey provide a validated resource for gathering patient satisfaction in a number of settings, but the system includes a ©benchmarking Jones & Bartlett database Learning,to compare anLLC organization with others© that Jones are & Bartlett Learning, LLC NOTsimilar. FOR The SALEdatabase OR incorporates DISTRIBUTION data from commercial and MedicaidNOT FOR SALE OR DISTRIBUTION plans that has been collected for over a decade. CAHPS program sponsors can obtain reports that compare survey results to database benchmarks, access data from individual surveys, and receive customized reports for a © Jones & Bartlettfee. The Learning, database has LLC become an important source© Jones for research & Bartlett into con Learning,- LLC NOT FOR SALEsumer OR evaluations DISTRIBUTION of healthcare quality in each ofNOT the surveyFOR SALEdomains. OR DISTRIBUTION

32 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC OtherNOT MethodsFOR SALE of Listening OR DISTRIBUTION to the Voice of the CustomerNOT FOR SALE OR DISTRIBUTION Survey methods are widely used in health care to hear the VOC. However, astute healthcare organizations have learned a number of other ways to understand customer requirements, including: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE• Formal OR DISTRIBUTION customer listening methods NOT FOR SALE OR DISTRIBUTION • Complaints/appeals/grievances • Customer comments and questions • Focus groups • Retention/referral analyses © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Kano model NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Informal customer listening methods • Short informal surveys • Community networking • Web site © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTOne of FOR the most SALE useful OR ways DISTRIBUTION of determining customer dissatisfactionNOT is FOR SALE OR DISTRIBUTION by analyzing customer complaints to determine system issues and trends. For example, if customers register a large number of complaints about the noise level on a hospital unit, the staff should evaluate the sources of the © Jones & Bartlettnoise and Learning,work to eliminate LLC them. In some cases,© the Jones trend &in Bartlettnumber Learning, LLC NOT FOR SALEof complaints OR DISTRIBUTION also can be helpful in discerning targetsNOT forFOR intervention. SALE OR DISTRIBUTION Many healthcare organizations monitor their complaint logs, often by capturing complaints in a database and categorizing them for analysis. Tracking these complaint categories can help quality improvement staff © Jones & Bartlett Learning,to determine LLC upward trends in certain© Jones issues that, & Bartlett although Learning, they may not LLC NOT FOR SALE OR DISTRIBUTIONhave reached a critical threshold, mayNOT represent FOR opportunitiesSALE OR DISTRIBUTIONfor improvement. Complaints in provider organizations are usually handled through a formal process such as that described in example 2-1, but complaints in payer organizations are managed somewhat differently. Because state and federal© Jones oversight & Bartlett agencies considerLearning, customer LLC complaints to be important© Jones & Bartlett Learning, LLC indicatorsNOT FOR of health SALE plan OR quality DISTRIBUTION and access to care, a system of managingNOT FOR SALE OR DISTRIBUTION these problems has evolved that generally involves three levels of severity:

1. Complaint—a health plan member calls the member service line to © Jones & Bartlettcomplain Learning, about a LLCservice, provider, or to request© Jones assistance & Bartlettreceiving Learning, LLC NOT FOR SALEa ORservice DISTRIBUTION that has been denied. If the member NOTservice FOR coordinator SALE can OR DISTRIBUTION resolve the issue at that encounter, the complaint is considered closed.

VoiCe of the Customer 33

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT2. gFORrievance SALE—if ORthe memberDISTRIBUTION service coordinator is unable toNOT resolve FOR SALE OR DISTRIBUTION the complaint, then the complaint is usually converted to a grievance, which escalates to health plan staff for further review to determine if the complaint can be decided to the member’s satisfaction. If the result is not acceptable to the member, the next step is an appeal. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 3. Appeal—if the health plan has not resolved the grievance to the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION member’s satisfaction, then the issue is referred to an outside arbiter, such as an administrative law judge, for final adjudication. This level generally represents the final step in the process.

© Jones & Bartlett Learning,Health LLC plans track the appeals© andJones grievance & Bartlett process Learning,to find opportu LLC- NOT FOR SALE OR DISTRIBUTIONnities for improvement, as wellNOT as indications FOR SALE of the OR effectiveness DISTRIBUTION of its utilization management programs.

© eJonesxample & Bartlett 2-1 c omplaintLearning, LLClog analysis © Jones & Bartlett Learning, LLC NOTPerfect FOR Sat Hospital SALE maintains OR DISTRIBUTION a customer complaint log that allows entry ofNOT pa- FOR SALE OR DISTRIBUTION tient complaints either directly by patients via the Web site or by any staff member who receives a complaint from a customer. As the data are entered into the log, each complaint is categorized into one of five domains: 1) staff, 2) facilities, 3) dietary/nutrition services, 4) administrative functions (e.g., billing, collections, etc.), and 5) physicians. The staff tracks the rate of complaints per 1,000 patient © Jones & Bartlettdays by Learning, graphing them LLC on a control chart, adding a new© point Jones each month.& Bartlett When Learning, LLC NOT FOR SALEa point OR indicatesDISTRIBUTION a special cause, the staff immediately launchesNOT FOR a Root SALE Cause OR DISTRIBUTION Analysis (RCA) to determine the underlying cause. The staff also evaluates the trend of complaints to determine if an upward (unfavorable) or downward (favorable) trend is present. If an upward trend is detected, the staff investigates the underlying causes using either a RCA or a Failure Modes and Effects Analysis (FMEA). © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONIn addition to surveys and NOTformal FOR complaint SALE processes OR DISTRIBUTION like that in Example 2-1, quality oriented organizations also develop methods of capturing customer comments and complaints that may be expressed in more informal ways. For example, many organizations will encourage employees to ©record Jones and &report Bartlett comments Learning, made by LLC customers during informal ©encoun Jones- & Bartlett Learning, LLC NOTters during FOR theirSALE daily OR work. DISTRIBUTION For example, (true story) an employeeNOT at FOR a SALE OR DISTRIBUTION hospital observed a four-year-old sibling of another child skipping down the hallway singing “we’re gonna sue you!” She reported the observation to the risk managers at the hospital who intervened with the parents and helped © Jones & Bartlettdefuse theLearning, situation. LLCIn addition to mitigating obvious© Jones risks, these& Bartlett informal Learning, LLC NOT FOR SALEobservations OR DISTRIBUTION may also identify some other opportunitiesNOT FOR for improvement, SALE OR DISTRIBUTION such as cleaning services or dietary department performance.

34 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTFocus FOR groups SALE are typically OR DISTRIBUTION used to get more in-depth customerNOT views FOR SALE OR DISTRIBUTION regarding a concept, product, or service. These facilitated sessions are led by a moderator who leads a group of participants through a discussion on a particular topic that follows a plan with questions, prompts, tasks, and exercises. The success of a focus group depends on the moderator, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC who must generate interest in the subject, involve the entire group, direct NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the discussion loosely enough to allow for digressions that might provide more information about the topic, and avoid directing the group in a way that reflects the sponsor’s expectations. The focus group is often most effective in gaining insights from group interactions, as well as individual © Jones & Bartlett Learning,contributions LLC to the discussion. For© Jonesexample, & if Bartlett a new product Learning, is being LLC NOT FOR SALE OR DISTRIBUTIONreviewed, the group might be givenNOT a prototype FOR SALE to examine OR DISTRIBUTION both individually and as a group. After group members have worked with the prototype, they can come together and discuss their reactions. Outcomes and deliverables from a focus group include notes and transcripts of the sessions,© Jones sometimes & Bartlett in audio orLearning, video format. LLC The facilitator or sponsor© usu Jones- & Bartlett Learning, LLC allyNOT creates FOR a report SALE summarizing OR DISTRIBUTION the purpose of the study, a descriptionNOT FOR SALE OR DISTRIBUTION of the procedures, detailed findings, and significant themes that emerged within and between focus group sessions. Focus groups are usually fairly inexpensive, but in the hands of an unskilled facilitator, the information © Jones & Bartlettgained from Learning, a session mayLLC be misleading. As with ©any Jones survey &technique, Bartlett Learning, LLC NOT FOR SALEdata from OR a DISTRIBUTION focus group can be distorted by poor memory,NOT FOR unwillingness SALE OR DISTRIBUTION to be truthful, and subject selection bias. Moderators must have the requisite skills to conduct effective group sessions and manage the vagaries of group behavior. © Jones & Bartlett Learning,Customer LLC retention and willingness© Jones to refer & are Bartlett often included Learning, as part LLC NOT FOR SALE OR DISTRIBUTIONof customer satisfaction surveys; forNOT example, FOR theSALE requisite OR questionsDISTRIBUTION are included in CAHPS surveys. Analysis of this data is important to determine the likelihood of customers returning to the organization. New customers almost always require some investment in marketing, advertising, and© otherJones outreach & Bartlett activities, Learning, while returning LLC customers do not require© Jones & Bartlett Learning, LLC thatNOT level FOR of investment. SALE OR Thus, DISTRIBUTION retaining current customers shouldNOT be a FOR SALE OR DISTRIBUTION high priority for any organization, and efforts to improve service quality and cost are the most effective ways of achieving that goal. Additionally, customers who would refer their family and friends to the organization © Jones & Bartlettare also an Learning, important indicator LLC of organizational quality© Jones and effectiveness, & Bartlett Learning, LLC NOT FOR SALEand these OR referredDISTRIBUTION customers generally cost less toNOT recruit. FOR Finding SALE the OR DISTRIBUTION

Kano moDel 35

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTunderlying FOR reasonsSALE forOR loss DISTRIBUTION of customers and unwillingness to referNOT helps FOR SALE OR DISTRIBUTION identify opportunities for improving the organization’s services. Finally, many institutions have informal methods of getting information from customers, such as conducting their own short surveys of customer satisfaction. These short questionnaires usually focus on a specific © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC aspect of service that one of the service units wishes to evaluate. For exam- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION ple, a patient care unit may wish to learn more about customer satisfaction with pain management, while the billing office may want to better understand complaints related to billing errors. Rather than change the process for the formal satisfaction survey, the unit may create and deploy © Jones & Bartlett Learning,a short LLC survey, often consisting of© justJones a few & questions Bartlett that Learning, are not on LLC the NOT FOR SALE OR DISTRIBUTIONstandard patient satisfaction instrument.NOT FOR These SALE short OR surveys DISTRIBUTION focus on a specific problem and can help identify some specific improvement issues fairly quickly. Although they lack the rigor of a typical patient satisfaction survey, they are widely used to help staff understand and resolve specific ©quality Jones problems. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTIn FORaddition SALE to the OR short DISTRIBUTION surveys, organizational leaders andNOT other FOR SALE OR DISTRIBUTION employees may participate in community activities and collect comments from customers and other stakeholders for analysis as part of the VOC effort. Some other contemporary methods of gathering customer opinions © Jones & Bartlettand comments Learning, may LLCinvolve interactive Web sites© that Jones provide & Bartlettthe organi Learning,- LLC NOT FOR SALEzation OR with DISTRIBUTION unstructured but readily available customerNOT FOR data. SALE OR DISTRIBUTION

kano model

© Jones & Bartlett Learning,Developed LLC by Professor Noriaki© Kano Jones in the & 1980s Bartlett as a methodLearning, of stimu LLC- NOT FOR SALE OR DISTRIBUTIONlating innovative product/serviceNOT design, FOR the SALE Kano ModelOR DISTRIBUTION classifies customer preferences into five categories:

1. Attractive quality—These attributes relate to customer surprise and © Jonesdelight & (i.e.,Bartlett they Learning,create high levelsLLC of customer satisfaction© Joneswhen & Bartlett Learning, LLC NOT achieved,FOR SALE but do OR not DISTRIBUTION cause dissatisfaction when not achieved).NOT These FOR SALE OR DISTRIBUTION attributes are not usually expected (e.g., free valet parking at a hospital) and often are not verbalized by customers. W. Edwards Dem- ing’s statement, “The customer never asked Mr. Edison for a light © Jones & Bartlettbulb” Learning, provides LLC an example of an unspoken© feature. Jones This & Bartlett dimension Learning, LLC NOT FOR SALE ORis often DISTRIBUTION ignored, since it is usually difficultNOT to ascertain. FOR SALE OR DISTRIBUTION

36 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT2. One-dimensional FOR SALE OR quality DISTRIBUTION—Quality attributes that result in satisfac-NOT FOR SALE OR DISTRIBUTION tion when fulfilled and dissatisfaction when not fulfilled are considered one-dimensional and are generally articulated by customers. Consider the dissatisfaction that travelers feel when a flight that is scheduled for 2:00 p.m. is delayed for two hours because of a © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC mechanical problem on the airplane. These factors are sources of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION competitive advantage for high performing organizations. 3. Must-be quality—Customers view must-be attributes as inherent in the product or service, and when not present, customer dissatisfaction is quick and serious. For example, a patient scheduled for a visit with © Jones & Bartlett Learning,a LLCspecific doctor will not be any© Jonesmore or &less Bartlett satisfied Learning,when the doc LLC- NOT FOR SALE OR DISTRIBUTIONtor enters the room, but will beNOT dissatisfied FOR SALE if another OR doctor DISTRIBUTION appears instead. These attributes are also usually not communicated by customers, since they are part of a basic expectation of the service or product feature. ©4. Jonesindifferent & Bartlett quality—Indifferent Learning, LLCquality refers to aspects that© Jonesare & Bartlett Learning, LLC NOTneither FOR good SALE nor bad,OR and,DISTRIBUTION consequently, they do not result in NOTeither FOR SALE OR DISTRIBUTION customer satisfaction or customer dissatisfaction. 5. reverse quality—In this domain, presence of an attribute creates dissatisfaction, and absence is associated with satisfaction, which © Jones & Bartlettemphasizes Learning, the fact LLC that not all customers are© Jonesalike. For & example,Bartlett Learning, LLC NOT FOR SALEsome OR patientsDISTRIBUTION may like the use of advanced diagnosticNOT FOR instruments SALE OR DISTRIBUTION like PET scanners, while others may find the technology intimidat- ing and unsatisfying.

Table 2-3 Kano model quality categories Quality© Jones category & Bartlett Attribute Learning, present LLC Attribute absent © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Satisfaction Dissatisfaction Satisfaction Dissatisfaction Attractive ⇑ ⇑ ⇔ ⇔ ⇔ One-dimensional ⇑ ⇓ ⇓ ⇑ Must-be ⇔ ⇔ ⇓ ⇓ ⇑ ⇑ © Jones & BartlettIndifferent Learning, ⇔LLC ⇔ ©⇔ Jones & ⇔Bartlett Learning, LLC NOT FOR SALEReverse OR DISTRIBUTION⇓ ⇑ NOT⇑ FOR SALE⇓ OR DISTRIBUTION

Kano moDel 37

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTProcedure FOR SALEfor Kano OR Model DISTRIBUTION process NOT FOR SALE OR DISTRIBUTION Kano model analysis really can be reduced to asking two basic questions about each attribute:

© Jones & Bartlett1. Rate Learning, your satisfaction LLC if the product has this© attribute?Jones & Bartlett Learning, LLC NOT FOR SALE2. OR Rate DISTRIBUTION your satisfaction if the product did notNOT have FOR this attribute? SALE OR DISTRIBUTION Responses to the questions should be one of the following:

• Very satisfied © Jones & Bartlett Learning,• LLCSatisfied © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Neutral (don’t care) NOT FOR SALE OR DISTRIBUTION • Dissatisfied • Very dissatisfied

1. Determine which product or service attributes are to be included in the analysis. © Jones & Bartlett 2. If Learning,the attribute LLC is new or not well understood,© Jones consider & Bartlett writing aLearning, LLC NOT FOR SALE ORshort DISTRIBUTION summary of the attribute without addingNOT judgmental FOR SALE language OR DISTRIBUTION (e.g., we think this will improve the use of the product). 3. Determine the method of obtaining customer feedback. Surveys may be done in paper format, online via a Web site, through focus groups, or telephone. © Jones & Bartlett Learning, 4. LLCCreate the survey instrument© Jonesusing the & questions Bartlett and Learning, response levels LLC NOT FOR SALE OR DISTRIBUTIONabove. NOT FOR SALE OR DISTRIBUTION 5. Field the survey and collect results. 6. Analyze the results using a Kano Model graph similar to Figure 2-2 to determine if the attribute is one that produces sufficient customer © Jonessatisfaction & Bartlett to warrant Learning, allocation LLC of resources to ensuring the© Jones attri- & Bartlett Learning, LLC NOT bute’sFOR presence.SALE OR Attributes DISTRIBUTION that create customer delight generallyNOT FOR SALE OR DISTRIBUTION receive more resources, while those that fall into the indifferent or reverse quality categories may be quickly eliminated.

© Jones & BartlettThe Learning,Kano Model LLC helps prioritize specific product© Jones or service & Bartlett attributes Learning, LLC NOT FOR SALEso that OR the DISTRIBUTION team can concentrate time and resourcesNOT onFOR those SALE issues ORthat DISTRIBUTION will create the greatest traction with customers.

38 Chapter 2 Define phase tools

RS © Jones & Bartlett Learning,EXC ILLCTERS/DELIGHTE © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

One Dimensional Quality Indifferent OneOne DiDimensionalmensional QuQQuality Quality PProductroduct Must-be Quality Product AAttributettribute AttribuAAttribute Fully © Jones & Bartlett Learning,AAbsentbsent LLC © Jones & Bartlett Learning,ImplemImplemented LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION BASIC NEEDS CE

PERFPERFORMANCE © JonesAttractive & Bartlett Quality Learning, LLC Reverse Quality © Jones & Bartlett Learning, LLC Very Dissatisfied NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Figure 2-2 Kano Model

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALETips and OR tricksDISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. The team must try to quantify the attribute by extent of deployment. Using a five-point scale from “not deployed” to “fully deployed.” The resulting value is then combined with the customer value from © Jones & Bartlett Learning,the LLC survey to produce a point© on Jones the Kano & BartlettModel graph. Learning, LLC NOT FOR SALE OR DISTRIBUTION2. The Kano Model graph demonstratesNOT FOR the three SALE major OR areas DISTRIBUTION of Attrac- tive, One-Dimensional, and Must-be quality. Note that the Indiffer- ent quality is represented by points clustered around the intersection of the x- and y-axes, and Reverse quality points would be reflected by a point that is very low on the customer satisfaction score, while © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Reverse quality points would be found in the lower right quadrant of NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION the graph. 3. Basic attributes generally receive the “Neutral” response to Ques- tion 1 and the “Dissatisfied” response to Question 2. Exclusion of these attributes in the product may have a negative impact on the © Jones & Bartlettsuccess Learning, of the product LLC in the marketplace. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

staKeholDer analysis 39

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT4. TheFOR Kano SALE Model OR can DISTRIBUTION be used in a number of circumstancesNOT other FOR SALE OR DISTRIBUTION than just evaluation of product attributes. For example, customers may be surveyed about proposed attributes of a new product or service and a Kano Model graph can be created. In this type of analysis, the customer is presented with varying levels of the attribute in a © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC product or service and asked the two questions. The ratings from the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION survey are then plotted as described previously. 5. Inclusion of performance or excitement attributes often requires a trade-off analysis against cost. Since customers frequently rate attributes or functionality as important, the first question may be © Jones & Bartlett Learning, LLCrephrased, “How much extra© Jones would &you Bartlett be willing Learning, to pay to LLCadd NOT FOR SALE OR DISTRIBUTIONor increase the amount of NOTthis attribute?” FOR SALE This ORinformation DISTRIBUTION may be better to help a team prioritize new attributes or increases in existing attributes and begin to calculate a return on investment. 6. Neutral or “Don’t Care” responses usually imply that the attribute © Joneswill neither & Bartlett increase Learning, customer satisfaction LLC nor motivate the customer© Jones & Bartlett Learning, LLC NOT toFOR pay SALEan increased OR DISTRIBUTION price for the product. Although it is temptingNOT FOR SALE OR DISTRIBUTION to simply dismiss these attributes, they may in fact serve an essential purpose for the product and may not be summarily eliminated. For example, the preoperative stop that is now required for surgical © Jones & Bartlettprocedures Learning, to verifyLLC patient identity and surgical© Jones details & mayBartlett not be Learning, LLC NOT FOR SALE ORsomething DISTRIBUTION for which a patient may be willingNOT to FORpay, but SALE it serves OR a DISTRIBUTION useful purpose in reducing errors.

The information obtained from the Kano Model analysis, specifically © Jones & Bartlett Learning,regarding LLC performance and excitement© Jones attributes, & Bartlett provides Learning, valuable input LLC NOT FOR SALE OR DISTRIBUTIONfor quality teams as well as for NOTstrategic FOR planning SALE and OR process DISTRIBUTION improvement. Designing the analytic tools requires forethought and some skill, and the results can help clarify customer requirements for product and service offerings. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTstakeholder FOR SALE OR DISTRIBUTION analysis NOT FOR SALE OR DISTRIBUTION Fundamental change in a process requires buy-in and support from mul- tiple sources, including executive leaders, senior managers, people in the © Jones & Bartlettdepartment(s) Learning, being LLC affected, suppliers, and customers.© Jones One & Bartlettof the first Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

40 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC evaluationsNOT FOR that SALE a team OR will DISTRIBUTION perform in preparing for a project is NOTdeter- FOR SALE OR DISTRIBUTION mining the important stakeholders. The team must consider everyone who might have an interest in the change and determine how they might react to the new process. A method of stratifying stakeholders in terms of importance to the project and influence on the outcome can be useful © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC to anticipate how to manage expectations and which stakeholders will NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION require greater attention. Additionally, an importance-influence matrix can graphically demonstrate who is most important to the project and who can be expected to exert influence to ensure project success. An example stakeholder matrix is shown in Figure 2-3. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Stakeholder Matrix 120

100 CEO © Jones & Bartlett Learning, LLC CFO © Jones & Bartlett Learning, LLC VP NOT FOR SALE OR DISTRIBUTION80 VP Provider NOT FOR SALE OR DISTRIBUTION Quality Relations

60 �202464 81012 Influence SVP Health Servicess VP Marketing © Jones & Bartlett Learning, LLC 40 © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONSr. Director Quality Director AccreditationNOT FOR SALE OR DISTRIBUTION 20

Stakeholder Importance Influence Magnitude VP Quality 80 80 6400 © JonesSr. &Director Bartlett Quality Learning,90 LLC 30 2700 © Jones & Bartlett Learning, LLC NOT FORSVP HealthSALE Services OR DISTRIBUTION40 50 2000 NOT FOR SALE OR DISTRIBUTION VP Marketing 30 40 1200 Director Accreditation 40 30 1200 VP Provider Relations 60 80 4800 CEO 20 90 1800 © Jones & Bartlett Learning,CFO LLC 30 90 © Jones2700 & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 2-3 Stakeholder matrix

proCess mapping 41

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTProcedure FOR SALEfor stakeholder OR DISTRIBUTION analysis and diagram NOT FOR SALE OR DISTRIBUTION 1. Assemble team to determine stakeholders for project. 2. Create a list of potential stakeholders for the project. 3. Create a survey instrument that ranks each stakeholder on two © Jones & Bartlettdimensions: Learning, importance LLC to the project and ©influence Jones on & the Bartlett project. Learning, LLC NOT FOR SALE4. ORAllow DISTRIBUTION the team to rank each stakeholder onNOT the twoFOR dimensions SALE OR on DISTRIBUTION a Likert scale (usually 1–9). 5. Enter the scores into a spreadsheet and average the rank scores for each stakeholder in each domain to create a table like that shown © Jones & Bartlett Learning, LLCin Figure 2-3. Note the column© Jones labeled & Bartlett“Magnitude,” Learning, which is LLC the NOT FOR SALE OR DISTRIBUTIONproduct of the two scores forNOT importance FOR SALE and influence. OR DISTRIBUTION The magnitude parameter determines the “size” of the bubble on the matrix. 6. Create a bubble chart like that shown in Figure 2-3 from the table by selecting the chart from the list of potential charts in Excel® using all three columns of data. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tips and tricks 1. If there is a chance that the stakeholder may have a negative influence on the project, the scale can be expanded to include negative © Jones & Bartlettnumbers. Learning, For example,LLC the Likert scale might© Jones range from& Bartlett -5 to +5, Learning, LLC rather than 0 to 9. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. The scale can be expanded (as shown in Figure 2-3) to any size (e.g., 0 to 100). Wider scales provide more choices and often avoid situations in which people may want to use 2.5 or 3.8 values. 3. Excel provides a method of placing text labels on each bubble as in © Jones & Bartlett Learning, LLCFigure 2-3. The precise technique© Jones can & beBartlett found inLearning, Excel Help LLC in NOT FOR SALE OR DISTRIBUTIONthe topic “Add data labels NOTto a chart” FOR under SALE the OR subtopic DISTRIBUTION “Create a custom label entry.”

©Process Jones & Bartlett maPPing Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Process mapping is a method of producing a workflow diagram that provides a graphic description of a process and related subprocesses. Process maps are ubiquitous tools for quality improvement teams to provide all stakeholders with a rapidly assimilated view of the process, as well as to hone © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in on specific steps that contribute to process variation or nonvalue added NOT FOR SALEwork. OR Process DISTRIBUTION flowcharts are the result of the processNOT mapping FOR SALE approach. OR DISTRIBUTION

42 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ProcedureNOT FOR for SALE creating OR a DISTRIBUTION process flowchart NOT FOR SALE OR DISTRIBUTION 1. Determine boundaries—establish the starting and ending points for the process 2. List the process steps—the level of detail depends on the use of the © Jones & Bartlettflow Learning,diagram; for example,LLC if the flowchart is to© be Jones used to & provide Bartlett an Learning, LLC NOT FOR SALEoverview OR DISTRIBUTION for senior managers, less detail will beNOT needed FOR than SALE if it is toOR DISTRIBUTION be used by a process improvement team to find intervention points. 3. Put the steps in time sequence—the steps identified above should be placed in order based on when they occur in the process. Some may © Jones & Bartlett Learning,occur LLC in parallel, while others© will Jones follow & an Bartlett ordered pattern.Learning, Many LLC NOT FOR SALE OR DISTRIBUTIONteams perform this task usingNOT a whiteboard FOR SALE or small OR notepaper, DISTRIBUTION but it can just as easily be accomplished with a software program like Microsoft Visio®. 4. Draw the flowchart using appropriate symbols—flowcharting has a number of symbols to represent specific types of process steps, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC as shown in Figure 2-4. Although hundreds of flowchart symbols NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Document/Report © Jones & Bartlett Learning, LLCProcess © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Termination Predefined © Jones & Bartlett Learning, LLC Process © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Off-page reference Decision © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Data Process Start Source © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 2-4 Basic Flowchart Symbols

proCess mapping 43

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT areFOR available SALE in OR software DISTRIBUTION programs, the basic symbols in FigureNOT 2-4 FOR SALE OR DISTRIBUTION should suffice for most situations. 5. Obtain feedback on the flowchart from process owners and users— ensure that process owners and key process users agree with the flowchart before finalizing. It is often helpful to have a formal review © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC process and sign off as a criterion for flowchart adoption. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 6. Finalize the flowchart and distribute to appropriate stakeholders. The resulting flowchart should resemble the chart shown in Figure 2-5.

© Jones & Bartlett Learning,Tips LLC and tricks © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Flowcharts benefit from both process user input and direct observation. Process users often have a concept of the process that may not conform to reality (i.e., because of constraints in the process, “workarounds” have become incorporated into the process flow that © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC are now second nature to everyone involved). Thus, part of process NOT mappingFOR SALE may involveOR DISTRIBUTION a “walk through” of the process to try NOTto detect FOR SALE OR DISTRIBUTION variation that should be incorporated into the process map.

Risk Stratification © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tier 1 Tier 2 Tier 3 Tier 4 (Low Risk) (Moderate Risk) (Moderate Risk) (High Risk)

Educational Educational Educational Educational Materials Materials Monitoring Materials Materials © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC

NOT FOR SALE OR DISTRIBUTIONMember MemberNOT FOR SALE OR DISTRIBUTION Agrees to Agrees to Intervention Intervention

Yes No Yes NoNo

Case Health Coach Monitoring Monitoring © Jones & Bartlett Learning, LLC © JonesManagement & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Figure 2-5 Basic flowchart for diabetic care management program

44 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT2. The FOR process SALE map canOR be DISTRIBUTION created individually or as a group. AlthoughNOT FOR SALE OR DISTRIBUTION the group approach often takes more time, it usually offsets the time gaining feedback from stakeholders on a flowchart created by an individual. 3. Many teams create two flowcharts during this stage: one for the cur- © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC rent state and one for the ideal state. The current state flowchart NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION details the process in its present condition, complete with workarounds and other variation, while the ideal state flowchart provides the best possible process flow with variation and workarounds either removed or revised to accommodate ideal process flow. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION siPoc Process maP SIPOC is an acronym for Suppliers, inputs, Process, Output, and Cus- tomers© Jones and is &used Bartlett as a general Learning, description LLC of the major process domains.© Jones & Bartlett Learning, LLC In most cases, quality will be judged by the output of a process, but in NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION process measures are used to gauge the efficiency and effectiveness of the process. Process outputs in a healthcare situation are usually services, such as a lab test or an imaging study or a diagnosis and subsequent treatment plan. In some cases, the quality of an output is difficult to assess, such as © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC in a complex diagnostic situation when the output (diagnosis) is tentative NOT FOR SALEand may OR take DISTRIBUTION time to unfold. In many of these cases,NOT output FOR is SALEmeasured OR DISTRIBUTION indirectly by patient satisfaction with the outcome, rather than the accu- racy of the outcome. In any case, efforts to improve output quality are directed at the preceding domains—suppliers, inputs, and process. Thus, © Jones & Bartlett Learning,understanding LLC each of these components© Jones is important& Bartlett to Learning,any improve LLC- NOT FOR SALE OR DISTRIBUTIONment project. An example of a SIPOCNOT process FOR map SALE for performing OR DISTRIBUTION a laboratory test is shown in Figure 2-6. The SIPOC process map is the high level overview of the process and allows a project planner to have a quick understanding of the major components of the process. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC ProcedureNOT FOR for SALE SIPOC OR process DISTRIBUTION map NOT FOR SALE OR DISTRIBUTION 1. Identify suppliers, inputs, the basic process flow, outputs, and customers. 2. Using the template in Figure 2-7 (created in Microsoft Visio), © Jones & Bartlettplace Learning, each of the componentsLLC into the appropriate© Jones column. & BartlettCreate a Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

sipoC proCess map 45

Suppliers Inputs Process Output Customer

Clinical Pathologist Physician Request Physician Enters Requesting Lab Tech Entered into Laboratory Report Lab Request Physician © Jones & BartlettLab Suppliers Learning,Information SystemLLC © Jones & Bartlett Learning, LLC Order NOT FOR SALE OR DISTRIBUTIONReceived by NOT FOR SALE OR DISTRIBUTION Lab Enablers

Order Placed in Stat Order? No Insurers (for Prior Work Queue Authorization) © Jones & Bartlett Learning, LLC Yes © Jones & Bartlett Learning, LLC Lab Tech NOT FOR SALE OR DISTRIBUTION DispatchedNOT to FOR SALE OR DISTRIBUTION Collect Specimen

NOT FOR SALE OR DISTRIBUTIONTest Performed, NOT FOR SALE OR DISTRIBUTION Report Produced

Figure 2-6 SIPOC Process Map © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION high-level process flowchart for the process column using a flowcharting tool like Visio 3. Add details if needed, such as enablers. For example, if an insurer must authorize a test before it is performed, then the insurer could © Jones & Bartlett Learning, LLCbe considered an enabler under© Jones “suppliers.” & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Tips and tricks 1. The process flowchart for the SIPOC process map does not usually have the same level of detail as a value stream map or working flow- © Joneschart. & The Bartlett SIPOC Learning, diagram is oftenLLC paired with a traditional© Jonesflow- & Bartlett Learning, LLC NOT chartFOR that SALE shows OR much DISTRIBUTION more detail for in-depth process analysis.NOT FOR SALE OR DISTRIBUTION 2. Identifying the entries for each domain can usually be done through brainstorming with the well-formed team, but it also can be performed by a “walk around” observation of the process if ambiguities © Jones & Bartlettpersist Learning, after the LLC brainstorming session. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

46 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Brainstorming,NOT FOR SALE OR DISTRIBUTION Brainwriting, andNOT FOR SALE OR DISTRIBUTION nominal grouP technique Brainstorming and its variants, brainwriting and nominal group technique (NGT), are the most commonly used approaches to generating large num- © Jones & Bartlettbers of ideas Learning, in a relatively LLC short period of time. Nearly© everyoneJones &has Bartlett partici- Learning, LLC NOT FOR SALEpated in OR a brainstorming DISTRIBUTION session at one time or another,NOT but FOR it is likelySALE that OR DISTRIBUTION the level of preparation and planning that go into a successful brainstorming exercise may not be evident to participants. Brainstorming relies on group participation, and if a group is reticent or does not perform collaboratively, © Jones & Bartlett Learning,the other LLC two approaches (brainwriting© Jones or NGT) & Bartlettmay be preferable. Learning, LLC NOT FOR SALE OR DISTRIBUTIONBrainstorming sessions strive forNOT volumes FOR of ideas,SALE not OR necessarily DISTRIBUTION high quality suggestions, and certainly not fully formed plans. Some brainstormed ideas fail to survive later scrutiny and analysis, and so everyone in the session needs to know that any idea should be brought to the fore, regardless© Jones of how& Bartlett outlandish Learning, it might sound LLC at the time. Another impor© Jones- & Bartlett Learning, LLC tantNOT principle FOR underlying SALE OR brainstorming DISTRIBUTION is the absolute need to eliminateNOT FOR SALE OR DISTRIBUTION any criticism of new ideas during the session. Participants must feel free to express ideas in a noncritical, supportive environment, or the likelihood of gaining any new insights will be severely limited. If the group is unable to © Jones & Bartlettperform in Learning, this manner, LLC then brainwriting or NGT© may Jones be more & Bartletteffective Learning, LLC NOT FOR SALEapproaches. OR DISTRIBUTION Finally, members of the brainstormingNOT team FOR should SALE feel free OR DISTRIBUTION to build on others’ ideas. In other words, if other team members can add to an idea that has already been presented, they should be encouraged to do so. The synergies achieved in this way can often be beneficial to the final product. © Jones & Bartlett Learning,Procedure LLC for brainstorming © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION These sessions should be led by someone experienced in the technique. The leader must prepare for the session as follows:

• Creation of a clear problem definition—the problem should be © statedJones as &clearly Bartlett as possible, Learning, with specific LLC questions, (e.g., “How can© Joneswe & Bartlett Learning, LLC NOTstreamline FOR SALElaboratory OR flow DISTRIBUTION to improve turnaround time?”). BrainstormNOT- FOR SALE OR DISTRIBUTION ing sessions benefit from the specificity of the problem statement, since participants can focus on specific ideas that are germane to the issue. • Summarize background—the group will usually require a basic © Jones & Bartlettunderstanding Learning, of theLLC problem; although participants© Jones are &selected Bartlett for Learning, LLC NOT FOR SALEtheir OR expertise DISTRIBUTION in the issue, a summary of the fundamentalNOT FOR issuesSALE sur OR- DISTRIBUTION rounding the topic will help the group stay focused.

Brainstorming, Brainwriting, anD nominal group teChnique 47

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• Select FOR appropriateSALE OR DISTRIBUTIONparticipants—as noted previously, participantsNOT FOR SALE OR DISTRIBUTION must be selected for their expertise and understanding of the issue to be discussed, and the three types of participants are usually managers, process owners, and customers of the process. In some cases, that group may include external customers, but usually the group consists © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC of participants internal to the organization. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • Prepare for the session—ensure that all materials are prepared for the session and secure a location that facilitates the brainstorming process. Locations usually involve privacy and low levels of distractions, comfortable, and easily accessible for participants. Additionally, the © Jones & Bartlett Learning, LLCleader should prepare for the© situationJones &in Bartlettwhich group Learning, members LLClose NOT FOR SALE OR DISTRIBUTIONfocus and may require directedNOT questions FOR SALE to consider OR DISTRIBUTION in the process. For example, the leader may want to have questions ready like “What if a lab machine breaks? How should the process flow be modified?” or “How does the lab process flow accommodate emergencies?” The ses- © Jonession leader & Bartlett should also Learning, ensure that LLC all necessary supplies (timer,© record Jones- & Bartlett Learning, LLC NOTing FOR medium SALE like OR a whiteboard DISTRIBUTION or flipchart) are ready for the session.NOT FOR SALE OR DISTRIBUTION • Conduct the session—the session leader must conduct the session according to the rules of the brainstorming process outlined previously. Participants must feel empowered to express themselves freely © Jones & Bartlettin Learning,a nonthreatening LLC environment, and they ©must Jones feel that & Bartlettevery opin Learning,- LLC NOT FOR SALE ORion DISTRIBUTIONis valued by the team. Conducting the sessionNOT FORis straightforward: SALE OR DISTRIBUTION • Assemble the team for the session • Briefly describe the problem and the process and then discuss any questions about either topic © Jones & Bartlett Learning, LLC• Identify a timekeeper and© a Jonesscribe to & take Bartlett down ideas Learning, as they occur LLC NOT FOR SALE OR DISTRIBUTION• Open the session for ideas.NOT In FOR most SALE cases, settingOR DISTRIBUTION a 10-minute time limit for each round of idea generation helps the group from becoming discouraged. Conduct as many 10-minute rounds as needed to exhaust new ideas © Jones• Tally & theBartlett ideas forLearning, the group LLC to review and for use in ©the Jones next & Bartlett Learning, LLC NOT FORphase, SALE which ORis often DISTRIBUTION “list reduction,” described later. NOT FOR SALE OR DISTRIBUTION

Variants—brainwriting and nominal group technique (NGT) Brainwriting is used when brainstorming is hampered by poor group © Jones & Bartlettdynamics, Learning, such as oneLLC or two dominant participants© Jones or &a particularlyBartlett Learning, LLC NOT FOR SALEdifficult OR DISTRIBUTIONsubject for discussion. Brainwriting is similarNOT toFOR Nominal SALE Group OR DISTRIBUTION Technique as a method of getting information from participants that may

48 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC notNOT be willing FOR toSALE share. ORThe DISTRIBUTIONtwo techniques are similar in that participantsNOT FOR SALE OR DISTRIBUTION write their ideas on a sheet of paper, rather than expressing them verbally in the group. The differences between the two approaches are listed in Table 2-4. One interesting variant of the brainwriting procedure is the use of diagrams instead of word descriptions for idea generation; thus, © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC if a product design is the subject of the brainstorming session, partici- NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION pants might use figures or diagrams on the brainwriting sheets rather than describe the design in words.

© Jones & Bartlett Learning,Multivoting LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONOnce the brainstorming session is NOTcompleted, FOR theSALE large OR number DISTRIBUTION of ideas needs to be reduced to a manageable few, and two methods of performing this task are multivoting and affinity diagrams. This section discusses multivoting, which is preferable to a single up and down vote on each idea because© Jones it allows & Bartlett an idea that Learning, is favored LLCby all team members, but perhaps© Jones & Bartlett Learning, LLC notNOT the topFOR choice SALE of anyOR of DISTRIBUTION the group, to rise to the top of the priorityNOT FOR SALE OR DISTRIBUTION list. Additionally, the group can consider the complete list and any potential synergies during a multivoting exercise, which provides some context around the voting. Multivoting is useful as a group tool to narrow a long © Jones & Bartlettlist of possibilities Learning, into LLCa manageable, prioritized subset.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Procedure for multivoting Supply each team member with 10 slips of paper and a pencil, and have a whiteboard or flipchart to use for listing all of the options and recording © Jones & Bartlett Learning,votes. TheLLC facilitator should decide© how Jones many & itemsBartlett can beLearning, on the final LLC NOT FOR SALE OR DISTRIBUTIONreduced list. In general, up to ten NOTrounds FOR of voting SALE may OR be DISTRIBUTION necessary to reach the final tally, but in most cases, only four or five rounds are usually needed to reduce a list.

1.© JonesDisplay &the Bartlett list of options Learning, and combine LLC any obviously duplicated© Jones & Bartlett Learning, LLC NOTitems. FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Number the items on the list. 3. Working individually, each team member selects five items that he or she feels are most important and then ranks the choices © Jones & Bartlettin order Learning, of priority, LLC with the first choice ranking© Jones highest. & Bartlett Each Learning, LLC NOT FOR SALEchoice OR DISTRIBUTION is written on a separate piece of paper,NOT with FOR the SALE ranking OR DISTRIBUTION underlined in the lower right corner.

© Jones & Bartlett Learning, LLC. NOT FOR SALE OR DISTRIBUTION. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 72147_CH02_FINAL.indd 48 10/21/11 4:03:58 PM NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FOR SALE ORDISTRIBUTION © Jones& BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC 72147_CH02_FINAL.indd 49 NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC Table 2-4 Comparison of brainwriting and NGT Brainwriting NGT Participant • Some group members are substantially more vocal than others • Some group members are substantially more vocal than others factors

© • Some group members think better in silence • Some group members think better in silence Jones • Some group members may not participate due to shyness or • Some group members may not participate due to shyness or a feeling of intimidation a feeling of intimidation & • All or some team members are new to the effort Bartlett • All or some team members are new to the effort • The issue is controversial or has created conflict within the organization • The issue is controversial or has created conflict within the Learning, organization Procedure • Clearly state the subject of the brainstorming exercise and • Clearly state the subject of the brainstorming exercise and ensure that everyone under- ensure that everyone understands the issue stands the issue LLC. NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FOR SALE ORDISTRIBUTION © Jones& BartlettLearning,LLC • Hand out a sheet of paper to eachNOT FORSALEORDISTRIBUTION participant© Jones&BartlettLearning,LLC • Allow 5–10 minutes for each team member to individually write down ideas: as with any NOT • Each team member begins writing ideas on the page, brainstorming exercise, volume is more important than content

FOR usually for 1–2 minutes • Gather the group together and have each team member read one idea to the rest of the • At the end of the allotted time each person passes his/her group; the facilitator records each idea on a flipchart or whiteboard: SALE sheet to the left º No discussion is allowed during the idea sharing

OR • The next person reviews the prior person’s work and adds º As the exercise proceeds, ideas may be generated spontaneously and not from the team

DISTRIBUTION. new ideas to the sheet that enhance the initial idea or create members’ lists NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning, LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC a completely new subject º Team members may “pass” his or her turn, and may then add an idea on a subsequent • The cycle is repeated until the pages are filled and everyone turn. has had the opportunity to see every sheet º Set a time limit for the idea sharing and stop when the limit has been reached or when • After a few cycles, have team members read the best idea everyone has used all of their ideas from all ideas on the page in front of them • The facilitator leads discussion of each idea, with the following rules: • The facilitator lists these ideas on the flipchart or white Originator of an idea must agree to wording changes board for further discussion and clarification º NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC NOT FORSALEORDISTRIBUTION © Jones&BartlettLearning,LLC Ideas may be eliminated only by unanimous vote • The ideas are prioritized using list reduction techniques º like multivoting, in which the ideas are ranked by group º Group discussion should focus on clarifying meaning, explaining the idea, or answering questions 10/21/11 4:03:58 PM members in successive secret ballots until the list is narrowed to three or four choices • Ideas should be prioritized by the group using list reduction techniques like multivoting © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

50 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT4. The FOR facilitator SALE collects OR DISTRIBUTION the papers, shuffles them, and then recordsNOT FOR SALE OR DISTRIBUTION the tally on the flipchart or whiteboard. It is usually best to have a scribe record the individual rankings next to each item, and then to total the rankings for each selection. 5. If a decision is clear after any of the voting rounds, the process may © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC stop. Otherwise, the facilitator conducts a brief discussion of the NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION vote to review the voting data, emphasizing those items with large ranges in ranking (e.g., votes of both 1 and 5 ratings), to identify any apparent misunderstandings of each item. The discussion should not produce pressure on anyone in the group to change their vote. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION example 2-2 Multivoting A hospital team from three departments was tasked with developing a list of key customers to contact regarding a new service. The group brainstormed a list of 32 possible names, which exceeded the limit of funding that had been budgeted. To reduce© Jones the list &to theBartlett budgeted Learning, number of 18 LLCpotential contacts, the group used© Jones & Bartlett Learning, LLC multivotingNOT FOR to identify SALE the OR top 18DISTRIBUTION candidates. A facilitator conducted the exerciseNOT FOR SALE OR DISTRIBUTION according to the procedure outlined in the text, and during each voting round, group members selected six names to be prioritized. After the third round of voting, the list had been successfully narrowed to 18 names with rankings to guide the outreach efforts. The top ten customers had fairly homogeneous voting scores, but the remaining eight scores had a broader distribution of votes, indicating less agree- © Jones & Bartlettment of the Learning, group on the LLCpriority scores for the last eight customers.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Affinity diagrams An affinity diagram graphically represents large numbers of ideas, opinions, or issues in a framework that demonstrates natural groupings. The © Jones & Bartlett Learning,diagram LLC is created using the affinity© Jones process, & which Bartlett is conducted Learning, after LLC NOT FOR SALE OR DISTRIBUTIONbrainstorming or one of its variants.NOT This FOR approach SALE can OR be DISTRIBUTION used as an alternative to multivoting, or it can be used before multivoting when a list of possibilities is so long that it is unmanageable. Two particular situations lend themselves to the affinity process: © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT• Sifting FOR through SALE large OR volumes DISTRIBUTION of data to find patterns—for exampleNOT FOR SALE OR DISTRIBUTION to categorize a population of patients into demographic categories for further analysis of utilization patterns. • Encouraging new patterns of thinking—the affinity process encour- © Jones & Bartlettages Learning,people to think LLC quickly and creatively, and© Jones so may & help Bartlett team Learning, LLC NOT FOR SALEmembers OR DISTRIBUTION find new perspectives on a problem. NOTThe use FOR of brainstorm SALE OR- DISTRIBUTION ing as the first step in the affinity process ensures “out of the box” thinking if done properly.

Brainstorming, Brainwriting, anD nominal group teChnique 51

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Cross Focus Two Way for Senior NOT FOR SALE OR DISTRIBUTION NOT FORManagers SALE OR DISTRIBUTION Departmental Communications Communications Communications Communications Cross Functional Systems in Place Open Door Policy Communication

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Senior Meetings Involvement Job Security Commitment Management Reward Systems Time for Manager Innovative Culture Involve Middle and Senior Managers in Leadership Focus

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Create Focus Systems Systems Establish Schedule Measures Scorecard Monitoring Measurement Measurement Ensure Validity of Establish Measure © Jones & Bartlett Learning, LLC Pilot Measurement © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Improvement Program Maintaining Effective Performance Need

© Jones & Bartlett Learning, LLC © Jones & BartlettPrior to Learning, LLC Pilot New Processes to Optimize Use Process Analysis Tools Implementation Refine Systems Define Processes to Meet Customer NOT FOR SALE OR DISTRIBUTION Process Focus NOT FOR SALE OR DISTRIBUTION

© Jones & Bartlett Learning, LLC © JonesAffinity Diagram & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2-7 Listen to Customers Operational Understand Use Correct Needs Correctly Customer Needs Interpret Customer Identify Customers Customer Focus Definitions of Output

52 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTIn general, FOR if SALE fewer than OR fifteenDISTRIBUTION items of information have been identiNOT- FOR SALE OR DISTRIBUTION fied as the target data set, the affinity process may be unnecessary. This process has been credited to Jiro Kawakita,4 who published the approach in the 1960s, and so affinity diagrams are often known as KJs in his honor.

© Jones & BartlettProcedure Learning, for creating LLC an affinity diagram © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Underlying principles include the following:

• The affinity process is best performed silently. As the process unfolds, the likelihood of disagreements rises, and allowing discussion may © Jones & Bartlett Learning,divert LLC attention to the overall ©task Jones at hand. & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION• Constitute the group from peopleNOT who FOR understand SALE theOR issues DISTRIBUTION well and can discern the underlying relationships. • Limit the group size to five or six participants. • Encourage team members to use their initial reactions to groupings, © Jonesrather than & Bartlett agonize over Learning, decisions. LLC Gradual movement toward© con Jones- & Bartlett Learning, LLC NOTsensus FOR will SALE usually OR require DISTRIBUTION an iterative process. NOT FOR SALE OR DISTRIBUTION • Disagreements over classification are handled simply. If team members cannot agree on a position for one of the ideas within a single classification, the idea is duplicated on another sheet of paper and © Jones & Bartlettput underLearning, other categories LLC until the team debriefs© Jones and resolves& Bartlett the Learning, LLC NOT FOR SALEconflict. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

The affinity process is conducted as follows:

© Jones & Bartlett Learning,1. Conduct LLC the brainstorming ©(or Jones variant) & sessionBartlett to generateLearning, a list LLC NOT FOR SALE OR DISTRIBUTIONof ideas. Write the ideas onNOT individual FOR SALEpieces ofOR paper DISTRIBUTION (such as Post-it Notes) for use by the team members in the next step. 2. Post the ideas randomly on the wall for everyone to view. Avoid trying to “precategorize” the ideas by grouping them in any © Jonesorder. & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC 3.NOTWithout FOR SALEconversation, OR DISTRIBUTION the team then can place the ideasNOT into FOR SALE OR DISTRIBUTION related groupings in the following manner: • Find two ideas that seem related in some way and place them in a column off to one side of the wall. © Jones & Bartlett• Seek Learning, other ideas LLC that seem related to those already© Jones selected & Bartlett and put Learning, LLC NOT FOR SALE ORaside, DISTRIBUTION and then add them to that group. NOT FOR SALE OR DISTRIBUTION

CritiCal-to-quality (Ctq) analysis 53

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT • FORRepeat SALE the process OR DISTRIBUTION until all of the ideas have been usedNOT in some FOR SALE OR DISTRIBUTION group. • If some ideas are left as “mavericks,” leave them in their own groups-of-one at this stage. 4. Create header cards for each group that capture the essential link © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC among the ideas contained in the group. The header card may NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION contain a short explanation of the grouping, as well as a simple title. Each header card is placed at the top of its respective group. Upon discussion, if two or more header cards seem to be related, they may be connected by a “superheader” card that is placed © Jones & Bartlett Learning, LLCabove those header cards.© At Jones this point, & Bartlett the group Learning, may engage LLC in NOT FOR SALE OR DISTRIBUTIONdiscussion to resolve someNOT of the FOR issues SALE with ideasOR DISTRIBUTIONthat have been placed in more than one group and the “mavericks.” 5. Complete the exercise by drawing the affinity diagram like that in Figure 2-7. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOTTips andFOR tricks SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 1. Ensure that the ideas are not in any particular order when starting the affinity process. If the notes are in some order at the start of the exercise, team members may be influenced in their thinking about © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC the groupings. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Allow plenty of time for step three. Some affinity processes have occurred over several days. For example, the idea notes could be posted in a public place and arranged by a large group of people over several days. © Jones & Bartlett Learning,3. LLCUse markers to complete the© Jones idea notes & Bartlett to improve Learning, visibility from LLC NOT FOR SALE OR DISTRIBUTIONa distance. If the affinity processNOT FORsession SALE is held ORin a DISTRIBUTIONlarge room, the information must be visible from a distance.

©c Jonesritical-to-quality & Bartlett Learning, LLC (ctq) analysis© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION The methods for obtaining and organizing the Voice of the Customer represent the hallmarks of the Define Phase of a QI project. Once the surveys are completed or the brainstorming session has been conducted, © Jones & Bartletthowever, Learning, a framework LLC for understanding the ©VOC Jones and &converting Bartlett itLearning, LLC to actionable information is useful to provide direction to the project. NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

54 Chapter 2 Define phase tools

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC Critical-to-qualityNOT FOR SALE (CTQ) OR attributesDISTRIBUTION are the key quantifiable customerNOT FOR SALE OR DISTRIBUTION requirements of a product or process that set performance standards or specification limits. CTQs help QI teams design initiatives that satisfy, or even delight, customers. One way of deriving CTQs from more general customer requirements is the CTQ tree. © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION Procedure for creating a CTQ tree 1. identify key customer requirements using the methods outlined previously (i.e., customer surveys, brainstorming [or its variants], © Jones & Bartlett Learning,affinity LLC diagrams, etc.). These© requirements Jones & Bartlett may be as Learning, broad as nec LLC- NOT FOR SALE OR DISTRIBUTIONessary to adequately capture theNOT customer’s FOR SALE needs. OR DISTRIBUTION 2. refine requirements using customer data or team experience. For example, if customer service is an issue, the surveys may have identified telephone response time as an issue. Similar to a Root © JonesCause Analysis, & Bartlett the team Learning, then begins LLC to break down the issue into© Jones its & Bartlett Learning, LLC NOTcomponent FOR SALE process OR steps DISTRIBUTION to determine which step(s) are problematic.NOT FOR SALE OR DISTRIBUTION The team completes this phase when quantifiable requirements are reached. Thus, if telephone response time is the problem, then the team may discover that the three quantifiable issues are call pick up time (CTQ = 2 rings), time-to-human response (CTQ = 2 layers of © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC answers to automated response system questions), and time on hold NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION (CTQ = 20 seconds). Those three elements form the branches of the CTQ tree (Figure 2-8), which is created in the same manner as other decision trees. 3. Confirm the final requirements with customers to ensure that the © Jones & Bartlett Learning,analysis LLC has yielded results that© Jonesare likely & to Bartlett produce Learning,a benefit. The LLC NOT FOR SALE OR DISTRIBUTIONconfirmation process may involveNOT anotherFOR SALE survey OR targeted DISTRIBUTION to these issues, informal conversations with key customers, or focus groups of a representative customer cohort.

©The Jones CTQ &tree Bartlett helps translateLearning, customer LLC language into quantifiable© Jones & Bartlett Learning, LLC requirementsNOT FOR that SALE can ORbe used DISTRIBUTION to develop improvement initiativesNOT that FOR SALE OR DISTRIBUTION have measurable outcomes. As such, the CTQ tree ensures that a comprehensive view of customer needs is used to identify key elements, and that an improvement team can transform relatively general needs into measur- © Jones & Bartlettable interventions. Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Completion of the Define phase 55

NOT FOR SALE OR DISTRIBUTIONFriendliness NOT FOR SALE OR DISTRIBUTION

Telephone Service Time on Hold

NOT FOR SALE OR DISTRIBUTION NOT FOR SALEIVR Time OR DISTRIBUTION

Lack of Appearance Customer Satisfaction with Literature © Jones & Bartlett Learning,Customer LLC Service © JonesReading & Bartlett Level Learning,5th Grade Level LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Figure 2-8 CTQ Tree © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION comPletion of the define Phase At the end of the Define Phase, the team should have completed all of the tasks listed in Table 2-5. These tasks serve as the basis for the next phase © Jones & Bartlett Learning,of the LLC project, the Measure Phase.© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

Table 2-5 Define Phase checklist

Done Task © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT✔ FORBusiness SALE champion/leader OR DISTRIBUTION identified NOT FOR SALE OR DISTRIBUTION ✔ Team composition complete ✔ Team members trained on appropriate improvement methods ✔ Team member participation documented through meeting minutes © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION

56 Chapter 2 Define phase tools

Done Task

✔ Project resources identified and secured © Jones & Bartlett✔ Learning,Customers segmented LLC and CTQs identified © Jones & Bartlett Learning, LLC NOT FOR SALE✔ ORInitial DISTRIBUTION data collection performed NOT FOR SALE OR DISTRIBUTION ✔ Project charter completed ✔ Process map complete ✔ SIPOC map complete and validated by team and managers © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION discussion questions 1. Describe the project charter. What is the purpose of the project © Jonescharter? & List Bartlett the major Learning, sections ofLLC the charter and provide a© brief Jones & Bartlett Learning, LLC NOTdescription FOR SALE of each. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. What is the Voice of the Customer (VOC)? Name three approaches to obtaining the VOC. 3. How is the CAHPS survey used in health care to obtain the VOC? © Jones & BartlettName Learning, three advantages LLC for using the CAHPS© survey Jones to understand& Bartlett Learning, LLC NOT FOR SALEcustomers. OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 4. Name three other methods of listening to customers and provide a brief description of each. 5. What is the Kano Model? How does it help define customer prefer- © Jones & Bartlett Learning,ences? LLC © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION6. How does stakeholder analysisNOT support FOR project SALE success? OR DISTRIBUTION What does a stakeholder matrix show? 7. Describe process mapping. What is the product of process mapping? 8. Create a flowchart of a process that you use in your work. 9.© JonesWhat is &the Bartlett function ofLearning, the SIPOC LLC process map? How does the© map Jones & Bartlett Learning, LLC NOTassist FOR project SALE managers OR DISTRIBUTION with gaining manager buy in? NOT FOR SALE OR DISTRIBUTION 10. Brainstorming helps teams produce ideas quickly. Describe the brainstorming process and describe variants like brainwriting and nominal group technique. When are these variants appropriate? © Jones & Bartlett11. Multivoting Learning, is a listLLC reduction technique used© afterJones brainstorming. & Bartlett Learning, LLC NOT FOR SALEDescribe OR DISTRIBUTION the multivoting process and how it isNOT applied FOR to prioritizaSALE OR- DISTRIBUTION tion of ideas.

referenCes 57

© Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC NOT12. CreateFOR SALEan affinity OR diagram DISTRIBUTION after brainstorming for a problemNOT or issue FOR SALE OR DISTRIBUTION that your organization faces, or select an issue from the following list: • How can we improve the way students learn about quality? • What can be done about the state of readiness of students for graduation? © Jones & Bartlett Learning, LLC © Jones & Bartlett Learning, LLC • Why is our staff satisfaction below benchmarks? NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION • What things do we need to consider in planning a perfect meeting? • What can be done to ensure proper disposal of recyclable mate- rial? © Jones & Bartlett Learning, LLC• How can information flow© Jonesbe improved & Bartlett within our Learning, organization? LLC NOT FOR SALE OR DISTRIBUTION• What can be done to ensureNOT fast FOR service SALE at the OR pharmacy DISTRIBUTION prescrip- tion counter? • What activities should we plan for the company Christmas party? 13. What is Critical to Quality (CTQ)? Describe the methods used to © Jonesgain CTQ& Bartlett data and Learning, how a CTQ LLC tree is created. © Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTION NOT FOR SALE OR DISTRIBUTION references

1. Agency for Healthcare Research and Quality. CAHPS ambulatory care survey. © Jones & BartlettRetrieved Learning, from https://www.cahps.ahrq.gov/content/products/PROD_Amb LLC © Jones & Bartlett Learning,- LLC NOT FOR SALE ORCareSurveys.asp. DISTRIBUTION NOT FOR SALE OR DISTRIBUTION 2. Agency for Healthcare Research and Quality. CAHPS facility surveys. Retrieved from https://www.cahps.ahrq.gov/content/products/PROD_FacilitiesSurveys .asp. 3. Agency for Healthcare Research and Quality. The CAHPS Connection newsletter. © Jones & Bartlett Learning, RetrievedLLC from https://www.cahps.ahrq.gov/content/CAHPSConnection/© Jones & Bartlett Learning, LLC NOT FOR SALE OR DISTRIBUTIONCAHPSConnectionArchives.aspNOT FOR SALE OR DISTRIBUTION 4. Ramon Magsaysay Award Foundation. (1984). Biography of Kawakita. Retrieved from http://www.rmaf.org.ph/Awardees/Biography/BiographyKawakitaJir.htm